Catheter Maintenance in the Home Parenteral Nutrition Patient = Reduced CRBSIs!
Donna Maslak, RN,MBA, Deborah Rossettini, RN, BSN, Laura Trento, MS, RD, CNSC, Melissa Leone, RN, BSN
Coram Specialty Infusion Services
The catheter maintenance bundle and education program were implemented by a single
branch of a home infusion company; the branch had more than 145 active HPN patients
throughout the study period. The protocol was instituted at the beginning of the fourth
quarter of 2012 and continued throughout 2013 for all branch patients on HPN, either as
a single therapy or in conjunction with other home infusion therapies. The protocol
included use of the following products:
 SwabCap®, a 70% alcohol impregnated disinfection cap that covers the needleless
connector between uses;
 Kendall™ AMD Antimicrobial Foam Disc, a flat foam disc impregnated with
polyhexamethylene biguanide hydrochloride (PHMB), an antiseptic from the same
family as chlorhexidine gluconate;
 AnchorDry, a moisture barrier that helps to protect the IV dressing during bathing;
and
 A work mat that included text describing common catheter complications and how
to avoid them. This mat was used to provide initial and ongoing patient education.
INTRODUCTION
Patients who receive parenteral nutrition (PN) are at high risk of acquiring a catheterrelated bloodstream infection (CRBSI). This may be due to several factors:
 Long catheter dwell times. These patients may require an indwelling catheter for a
long period of time, and often have multi-lumen catheters, thus increasing the
potential for bacterial ingress.
 Underlying disease state. These patients may have a related disease, such as
malnutrition or a compromised immune status.
 Possible cross-contamination. These patients are at risk for cross-contamination
related to the possible presence of ostomies, fistulas, drainage tubes, and diarrhea.
Home PN (HPN) can be a life-saving therapy for these patients, and in many cases, it may
be required for the remainder of the patient’s life. Maintaining vascular access is a key
part of HPN, and therefore, consistent catheter maintenance practices are vital to protect
these patients from CRBSIs. Preventing CRBSIs can help avoid hospital readmissions and
help improve these patients’ quality of life.
A previous retrospective review, which assessed national catheter infection rates by
therapy over 21 months, identified that HPN patients had a CRBSI rate more than two
times greater than their non-PN home infusion counterparts. This result prompted this
home infusion provider to develop an HPN-specific catheter maintenance bundle and
accompanying education program that would prevent or reduce possible causes of CRBSI.
Recent literature has shown that HPN catheter infection rates can range from 1.01 to 8.8
per 1,000 catheter days.1, 2
OBJECTIVE
To prevent CRBSIs in patients receiving HPN with the implementation of a catheter
maintenance bundle, as well as an expanded education program. The goal of the protocol
is zero catheter infections.
1
2
3
Leone M. Central vascular access device infection rates with parenteral nutrition. Support Line (a newsletter of Dietitians in Nutrition Support). 2010;32(6):10-13.
Zhao VM. Characterization of post-hospital infections in adults requiring home parenteral nutrition. Nutrition. 2013;29(1):52-59.
CDC/NHSN Surveillance Definitions for Specific Types of Infections. Centers for Disease Control and Prevention website.
www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf. January 2014. Accessed March 20, 2014.
Prior to initiation of the bundle, a specialized educational offering was provided to all
patients and relevant staff:
 Company nurses and pharmacists were educated on use of the new products.
 Patients and physicians received a letter informing them of the program. Within the
letter, an educational document described each new product being used. Also,
company nurses or pharmacists provided HPN patients with face-to-face education
on use of the three new products.
 Pharmacists and non-clinical staff involved in ordering supplies for the patient were
educated on the program.
During the two-year period of the study (including the three quarters prior to
implementation of the protocol), we maintained ongoing records for all branch patients
receiving HPN to assess for CRBSI rates. CRBSIs were identified using the method used by
the Centers for Disease Control (CDC). (See Figure 1.)
Number of CRBSIs*
For the 8,982 catheter days assessed before the catheter maintenance protocol began,
19 catheter infections occurred, for a rate of 2.12 per 1,000 catheter days. For the 14,826
catheter days assessed after the protocol was implemented, 13 infections occurred, for a
rate of 0.88 per 1,000 catheter days. (See Figure 1.)
Catheter Days
0.88
8,892
13
19
Pre-Protocol
Post-Protocol
14,826
2.12
Catheter maintenance protocol started 10/1/12
*We characterize catheter infection as when any of the following are present:
• Fever over 100.4° not attributable to other health issues;
• Catheter exit site redness, drainage or cord; AND
• Blood/catheter culture or gram stain that confirms bacterial or fungal counts; OR
• The prescriber determines that the catheter is the most likely source of an infection (in which case, the
prescriber removes the catheter or treats the patient/catheter with anti-infectives).3
Catheter types included tunneled catheters, implanted ports, and peripherally inserted
central catheters (PICCs). Of note, PICCs presented with the highest infection rate of the
three catheter types, at almost four times the rate of implanted ports and more than
twice that of tunneled catheters. (See Figure 2.)
Figure 2: Results by Catheter Type, Pre- and Post-Protocol Combined
12,000
10,000
2.00
25
10,609
8,000
7,912
6,000
5,270
4,000
20
22
15
10
7
5
2,000
0
RESULTS
Catheter Infection
Rate/1,000 Days
3
Imp Tunneled
CatheterPortTypes
Catheter
PICC
Catheter Type
0
Imp
Tunneled
CatheterPort
TypesCatheter
PICC
Catheter Type
CRBSIs/ 1,000 Catheter Days
Patients on home parenteral nutrition are at high risk of acquiring catheter-related
bloodstream infections (CRBSIs). A catheter maintenance protocol was instituted in one
branch of a home infusion company over five quarters. Under this protocol, three antiinfective products, as well as related education and nursing care, were introduced:
SwabCap®, the AMD antimicrobial foam disc, and AnchorDry. Over the course of the
program, CRBSI rates decreased by 60%.
Figure 1: Results, Pre- and Post-Protocol
Number of CRBSIs
METHODOLOGY
Number of Dwell Days
ABSTRACT
1.98
1.80
1.60
1.40
1.20
1.00
0.88
0.80
0.60
0.57
0.40
0.20
0.00
Imp
Tunneled
Catheter
PortTypes
Catheter
PICC
Catheter Type
CONCLUSIONS
The incidence of CRBSIs declined with increased education and use of the catheter
maintenance bundle described above. The protocol was initiated on October 1, 2012 (Q4
2012), and decreased the rate of CRBSIs by 60% over the next five quarters. This infection
reduction protocol has now been rolled out to all branches of the company.